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Program to Enhance Communication of Life-sustaining Treatment Preferences Associated with Closer Adherence to a Person’s Wishes when Compared with Traditional Practices, Finds NIH-Supported Study

A program in which individuals used a standardized form signed by a physician to communicate their end-of-life care preferences on issues such as levels of medical intervention and tube feeding lead to significantly better adherence to treatment preferences than more traditional methods of communication, according to a new study.

The study, supported by the National Institute of Nursing Research (NINR), part of the National Institutes of Health, appears in the July issue of the Journal of the American Geriatrics Society. This study was the first to directly compare this program to traditional practices such as Do-Not-Resuscitate (DNR) orders.

The program, called Physician Orders for Life-Sustaining Treatment (POLST), is designed for individuals with progressive chronic illness or frailty. The POLST program, which is in use or under development in over 30 states, includes a standardized form on which patient preferences are listed as physician orders for cardiopulmonary resuscitation (CPR); medical interventions such as comfort measures (non-life-sustaining measures to relieve pain and suffering), limited intervention or full treatment; use of antibiotics; and tube feeding. The order forms are included with an individual’s medical charts as the person moves through the health care system.

Using 60-day chart data from more than 1,700 living and deceased long-stay nursing facility residents in Oregon, Wisconsin, and West Virginia, the study analyzed the levels of treatment received by residents with or without POLST forms or traditional medical orders such as a DNR order. The study found that residents who used a POLST form to indicate their preference for comfort care only were 59 percent less likely to receive life-sustaining medical interventions that were not requested, when compared to residents with DNR orders, suggesting that POLST promotes closer adherence to documented treatment preferences than DNR orders. Similarly, residents with POLST orders for comfort care only were 67 percent less likely to receive life-sustaining treatments than those with POLST orders for full treatment. Overall, residents with POLST forms were also more likely to have treatment preferences documented as medical orders than those without POLST forms.

"It is fairly common for nursing facility residents to have orders about CPR in their medical charts. However, CPR orders alone are not very helpful in telling the health care provider about the person’s interest in receiving other treatments," stated lead author Susan Hickman, Ph.D., associate professor in the schools of nursing at Indiana University and Oregon Health & Science University. "In our study, 98 percent of residents with POLST forms had orders about medical interventions beyond resuscitation, in comparison to just 16 percent without POLST forms. This means they had orders about their preferences for treatments such as hospitalization, antibiotics, and feeding tube use. POLST tends to provide much more specificity for care providers."

The study also found no significant difference in reported symptom frequency or in the level of symptom management provided to residents who were POLST users compared to non-POLST users. This finding indicates that the presence of a POLST order did not impact the degree of comfort care received by the residents.

"Many individuals and their families still struggle with a lack of continuity of care and poor communication with health care practitioners about their treatment wishes," noted NINR Director Patricia A. Grady, Ph.D., RN. "This study underscores the importance of identifying effective ways to make sure that the type of end-of-life health care requested by the individual is in fact provided. Health care professionals can use this information to help individuals make better informed choices about the type and level of care they wish to receive."

NINR supports basic and clinical research that develops the knowledge to build the scientific foundation for clinical practice, prevent disease and disability, manage and eliminate symptoms caused by illness, and enhance end-of-life and palliative care. For more information about NINR, visit the Web site at www.ninr.nih.gov.

About the National Institutes of Health (NIH):
NIH, the nation's medical research agency, includes 27 Institutes and Centers and is a component of the U.S. Department of Health and Human Services. NIH is the primary federal agency conducting and supporting basic, clinical, and translational medical research, and is investigating the causes, treatments, and cures for both common and rare diseases. For more information about NIH and its programs, visit www.nih.gov.